Our Lady of Providence Visit – Adult Release

Your Name(Required)

First Last

Your Email(Required)

Name & Relationship of Emergency Contact(Required)

In the event of an emergency and I am unable to communicate, I hereby give permission for transportation to a hospital for emergency medical treatment. In the event of treatment beyond emergency medical treatment is required, please contact the emergency contact listed:

Emergency Contact Phone(Required)

Please list all allergic reactions (medications, foods, plants, insects, etc.)

Your Doctor

Your Doctor's Phone

Health Plan Carrier:

Policy #:

Signature

I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend the Office for Vocations and the Roman Catholic Bishop of Fall River, Corp Sole, its officers, directors, agents, employees, or representatives associated with the field trip/event from any and all liability claims, loss or damage arising from or in connection with my participation in the field trip/event:

Today's Date